The quality of healthcare is a cornerstone of the healthcare system and has a direct impact on health outcomes. The literature offers various definitions of “quality of care,” one of the most widely cited describing it as the extent to which healthcare services increase the likelihood of desired health outcomes and are consistent with current professional knowledge (1).
In 2001, the Institute of Medicine in the United States published a foundational report on the quality of healthcare, presenting a comprehensive framework for assessing the quality of healthcare systems (2). Within this framework, six core domains were defined for improving the quality of care delivered within healthcare systems:
The National Health Insurance Law (1995) establishes a standardized package of services delivered by the four health funds to all residents of the state. The importance of quality medical care is reflected in the wording of the law, which stipulates that it is founded on the values of “justice, equality, and mutual aid,” and further that “health services included shall be provided according to medical discretion, at a reasonable quality, within a reasonable time, and at a reasonable distance from the patient’s place of residence” (3).
The Ministry of Health was assigned responsibility for overseeing the implementation of the law, and in its wake, bodies were established with the aim of “accompanying and evaluating the impact of the National Health Insurance Law on health services in Israel, their quality, efficiency, and cost.” These include the Health Council and the National Institute for Health Services and Health Policy Research in Israel. In recognition of the importance of measurement and oversight, the Quality Indicators Program for Community Medicine in Israel was established, initially as a research project led by a team of researchers from Ben-Gurion University under the direction of Prof. Avi Porat, and funded by the National Institute for Health Services and Health Policy Research. The project was carried out in collaboration with the four health funds, the Ministry of Health, the Israeli Medical Association, and its professional associations.
Following its success in developing a quality indicators framework for community medicine, the project was adopted by the Ministry of Health and in 2004 became a permanent national program (the National Program for Quality Indicators in Community Healthcare) under the leadership of the National Institute and funded by the Health Council. The program’s first report was published in 2004 and presented data for the years 2001–2003. Additional reports presented data for subsequent years (previous reports are available on this site). In May 2010, the program’s management changed hands, with oversight transferred to a team from the Hadassah-Hebrew University School of Public Health in Jerusalem, led by Prof. Orly Manor, and from 2017 by Prof. Ronit Calderon-Margalit.
In the OECD’s 2012 report on Israel’s healthcare system, the program received considerable praise as a leading initiative among member countries. Since then, the program has expanded both in its areas of measurement and in its capacity to identify gaps in quality of care.
The program’s goal is to maintain ongoing and dynamic measurement of the quality of preventive, diagnostic, curative, and rehabilitative services provided in the community, and in doing so supply policymakers and the public with information on the quality of medical care delivered by the health funds. All of this is aimed at improving and enhancing the medical services provided to the residents of Israel.
To achieve this goal, the program publishes community healthcare quality indicators annually. This ongoing monitoring tracks changes in care quality over time and identifies areas needing improvement in both information systems, data collection, and health services. Israel’s healthcare quality is also assessed through comparisons with other countries that publish similar community care indicators.
The program management team, based at the Hadassah–Hebrew University School of Public Health, includes clinicians, researchers, epidemiologists, and pharmacists. It conducts internal discussions on new indicators and updates to existing ones, with subject-matter experts invited to participate in discussions.
The management team’s discussions focus on the suitability of indicators for the program and include a comprehensive review of the professional literature, a review of guidelines both internationally and in Israel, an examination of whether the indicators exist in other quality indicator programs worldwide, and a discussion of their suitability for the program according to the following criteria:
The indicator set includes several types:
Following internal discussion within the program management team, the Steering Committee conducts a broader review. The committee includes representatives from the four health funds, observers from professional associations, the Ministry of Health, and the Israel National Institute for Health Policy Research, as well as a public representative. Members are presented with the scientific background, the rationale for measurement, and relevant Israeli and international comparative data, with subject-matter experts contributing to the discussion.
An indicator is incorporated into the program after the Steering Committee has completed its deliberations and the four health funds have reached agreement on its wording.
The final stage is the implementation of the Steering Committee’s decision and the precise definition of the indicator within the IT Committee. This committee includes IT representatives from the four health funds and discusses how data are collected in each fund. The purpose of these discussions is to ensure standardized measurement according to uniform criteria.
A unified computerized system is used to define algorithms for calculating the indicators. This system enables standardization of workflows, reduces the risk of errors, and strengthens the reliability of the resulting data. The program management unit distributes a detailed algorithm manual to the four health funds.
The data are extracted from the health funds’ information systems and undergo a rigorous three-level quality control process:
The audits examine the processes, quality controls, and documentation, as well as corrective actions taken following previous audits. This approach supports continuous improvement in data production.
The quality control process is designed to ensure consistency, reliability, and validity of the data across all health funds. It also examines various data sources, such as laboratory systems, electronic medical records, and pharmacies, and includes sample checks of the software code used to generate the indicators.
Understanding and addressing existing health disparities is a critical national priority. Health disparities can arise from various factors, some of which are preventable or modifiable, including access to healthcare services, the living environment, and socioeconomic status. To monitor and reduce these disparities in Israel, a set of national measures (“Health Disparity Measures”) was developed, funded by the Institute for Health Services Research and led by the Ministry of Health’s Health Disparities Reduction Division. The National Program for Quality Indicators in Community Healthcare is responsible for developing and monitoring these measures using annual data from the health plans (Kupot Cholim).
In 2023, the first Health Disparities Report was published by the National Program for Quality Indicators in Community Healthcare in collaboration with the Strategy Division of the Ministry of Health. The report includes national data for the years 2015-2021, stratified by socioeconomic status, as well as a spatial analysis of the health and morbidity status of the Israeli population by district of residence, with a focus on the set of national measures that were adopted.
Since 2013, the Ministry of Health has been operating a National Program for Quality Indicators for General and Geriatric Hospitals, Psychiatric Hospitals, Mother & Baby Health Centers and Emergency Medical Services (Ambulances).
The data and findings are validated by comparing them with external data sources, including Central Bureau of Statistics health surveys, Ministry of Health surveys, and expert professional opinions. The use of multiple data sources strengthens the reliability and validity of the results.
Institute of Medicine. 1994. America’s Health in Transition: Protecting and Improving Quality. Washington, DC: The National Academies Press.
Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. PMID: 25057539.
Knesset (1994). National Health Insurance Law, 1994. State of Israel.
https://fs.knesset.gov.il/13/law/13_lsr_211132.PDF